Healthcare News & Insights

Failed sepsis EHR alert leads to surprising discovery

Alerts may be annoying to your hospital staff, and they might be overused in some cases. But they also provide opportunities to improve patient care, even if they may not be working as intended initially. One health system’s attempt to create an alert designed to root out sepsis ended up with a different, yet still positive, outcome. 

According to an article published in BuzzFeedelectronic-medical-record, Arizona’s Banner Health wanted to improve its protocol for the early detection of sepsis.

To do so, the health system created custom electronic health record (EHR) alerts that flag patients who are admitted to its hospitals with various symptoms that usually accompany sepsis, including irregular body temperature and high heart rates.

Each time a patient’s condition triggered an alert, hospital staff were told to evaluate patients for sepsis. However, often patients didn’t have the illness, which made staff frustrated about addressing the alarms and documenting the interaction. Some even wanted to disable the alerts entirely.

Unexpected findings

After two years, Banner Health analyzed the effect of its EHR alerts on sepsis rates to see how the initiative was working. The health system chronicled its results in the American Journal of Medicine.

Unfortunately, the alert wasn’t as effective as hoped – only about 25% of the patients who triggered the alert actually had sepsis.

Surprisingly, though, the alerts had an unintended consequence. Although the patients didn’t have sepsis, the majority of them were much sicker than the average patient.

Approximately one-fifth of hospital patients at Banner Health had illnesses that triggered the sepsis alert – but they accounted for almost 90% of all hospital deaths during that two-year time period.

In fact, compared with patients whose conditions didn’t trigger the alert, these patients were four times more likely to die the next day. They also had longer hospital stays, and they were more likely to have serious conditions such as chronic obstructive pulmonary disease (COPD) and kidney disease.

So the alerts actually were identifying critically ill patients – just not those with sepsis.

New approach

Because of this discovery, Banner Health decided to take a different tactic with its EHR alert. Instead of using it to find patients with sepsis, it tweaked the settings so it’s better able to identify vulnerable patients with illnesses that may have a severe impact on their health.

Now, when they hear the alert, staff are directed to give these patients extra health attention, closely evaluating their condition to see if they need additional interventions in the intensive care unit or a different treatment plan.

Banner Health is currently monitoring the results of this new initiative. It’s hoping that it’ll help save lives by identifying and addressing critical illnesses more quickly. The team is also working on a new EHR alert that’s more effective at identifying sepsis.

Takeaway for hospitals

The health system’s story serves as an excellent reminder to facilities that when working to improve quality of care in a hospital, any bumps in the road must be evaluated closely to see if there’s a way to benefit or learn from any missteps or issues.

Instead of treating them as burdens, or looking to place blame when something doesn’t work as intended, it’s important to see these stumbling blocks as opportunities for finding other alternatives that could be more effective.

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